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Republic of Sudan (North Sudan): national context

Sudan was the largest country Africa until July 9th2011 sharing borders with nine countries. On that date Sudan became two independent countries, the Republic of Sudan (North Sudan) and the Republic of South Sudan. The Republic of Sudan (RS) covers an area of around 1.7 million square km. and borders seven countries, Egypt and Libya in the North, Chad and Central African Republic in the West, Ethiopia and Eriteria in the East and the Republic of South Sudan in the South. It has a population of approximately 32 million. Administratively it is divided into 17 states, each in turn consists of several localities. The capital city of the Republic of Sudan is Khartoum located at the confluence of the Blue and White Niles. Due to scarcity of jobs in rural areas, people are migrating from rural to urban areas and it is estimated that the urbanization rate is around 4.3% per annum. The Republic of Sudan is a multiethnic multicultural country with many ethnic and tribal divisions and languages. Arabic is the official language of the country.

Political and Economic frameworks
Sudan has a long history with decentralization dating back to 1951. Decentralization was introduced as a system of governance compatible with the needs of the multi-ethnic and multi-cultural society of Sudan. Since 1991 the political and administrative structure of the country has been based on a presidential republic and a federal system. The system has passed through many stages of development until the Local Government Act 2003 was enacted, giving more authorities and responsibilities to the localities, particularly in the areas of health, education and development. Currently, there is a three-tier government system i.e. federal, state and local government.
Economically the GDP per capita had shown significant increase during the last five years (due mainly to increased oil revenues and the flow of foreign investments). Fifty percent of the government budget in 2005 was from oil revenues, but this has changed since 9th July 2011. Agriculture contribution to the GDP has decreased from 46.3 % in 2000 to 39% in 2005. Furthermore, agriculture remains the main source of income for two out of three people living in rural areas. Government spending on health care has improved over the last years due to the increasing government revenues although the rate is not proportionate to the overall increase in the total government expenditure.

Primary health care policies in Sudan
Sudan has started the PHC approach in 1976 in an attempt to achieve rural extension for the then limited urban based health services. The attempt was part of a five-year social development plan. Primary health care got re-emphasized in the National Comprehensive Strategy for Health in 1992 and in the 25-Year Strategic Health Plan 2003-2027 and the National Health Policy 2007.
Primary health care facilities include primary health care units (PHCU), dressing stations (DS), dispensaries, health centers and rural hospitals. In principle, PHC units are staffed by community health workers (CHWs), dressing stations are staffed by a nurse, and dispensaries are headed by a medical assistant. According to FMOH Health Facility Description and Renaming Policy, the minimum acceptable facility level for health services provision is now the Basic Health Unit which is structured and staffed to deliver the essential package of PHC services. PHC units and dressing stations are below the minimum standard and should be upgraded to become Basic Health Units. The health centre is the first referral point for the lower-level facilities. According to the standards, it is supposed to be headed by a physician (medical officer/GP). Lower level PHC health facilities (BHU and Health Centers) are supposed to be managed and financed by the localities. The rural hospitals, on average, have bed capacities of 40 to 100 beds and managed by State Ministries of Health (SMOH). Tertiary hospitals, including teaching, specialized, and general hospitals, are located in State capitals and are operated by the SMOHs. In addition, the FMOH operates 21 tertiary-level hospitals and specialized centers.

HRH in Sudan - current situation
There is, currently a total of 97.303 health workers in Sudan comprising over 20 different professions. According to the WHO criteria Sudan falls within the critical shortage zone considering the density of physicians, nurses and midwives (1.23 per 1000 people). This holds true despite the fact that the total density of the health workforce in RS (2.70) is above the WHO critical shortage benchmark of 2.30 per 1000 population.
Approximately 70 % of health personnel work in urban settings serving about 30% of the total country population. More than third of the overall health workforce in Sudan is located in Khartoum state as opposed to the other 16 states. The case is most illustrative among physicians where 65% of specialists are currently practicing in Khartoum. Thus the rural-urban imbalance is further distorted by the high concentration of the health workforce in Khartoum. For example there are 21 specialists for every 100.000 people in Khartoum compared to a ratio of only 0.8 per 100.000 in West Darfur state. Following on the geographical pattern of health services distribution, around 67 percent of health workers staff the secondary and tertiary facilities as opposed to only 33 percent in Primary health Care (PHC) settings.
The Republic of Sudan is lacking appropriate planning for HRH. Records of the Ministry of Health and other health care organizations have no planning documents in the domain of the health workforce. Not uncommonly, expansion in health care infra-structure and facilities occurs without paying enough attention to the need for health workers both in terms of numbers and qualities. The consequences have usually been a situation where health facilities are poorly functioning or completely non-functioning. Even when HRH planning was attempted in the country following the recent focus on health system development, the HR plan has come out again focusing on projection of staff numbers for different levels of health care.

Recent national policies on health workforce
During the past 5 years, the Federal Ministry of Health (FMOH) has managed to launch a package of health workforce policies through a process of wide consultation within the health sector and related bodies.The following policies have been so far prepared and introduced since 2001:

Doctor’s career pathway policy: this is mainly a deployment policy for all categories of doctors including generalist and specialist physicians. It also responds to the issues of career progression and promotion.

Technical and allied personnel career pathway policy: this policy focuses on similar issues pertaining to other categories of health workers including technicians and paramedical staff.

Health workforce training policy: this focuses mainly on the eligibility and selection criteria for internal and overseas training emphasizing priorities for training. The policy has also emphasized equal opportunity for training among health workers.

Continuing professional development (CPD) policy: this policy emphasizes continuing education for health personnel as a means for improving performance of the health system.

Internship policy: although internship for doctors is running for years, this policy was introduced to improve standards and guidelines for this period. The policy has also introduced internship period for categories such as dentists, pharmacists and health technicians

Sudan Declaration for promotion of nursing, midwifery and allied health professions: this policy was introduced jointly by the FMOH, Ministry of Higher Education and the WHO in 2001. It envisioned the upgrading of nursing and paramedical training to a university degree to improve the quality of health services.

Staffing norm policy: this policy came as part of the overall policy that addressed reorganization of health facilities in the country. The policy defines the criteria for staffing different types of health facilities with different types of health personnel.